Parkinsons Flashcards
Background
Cause not fully understood linked with genetic and environmental factors.
Progressive neuro-degenerative disorder mainly from loss of dopamine in the substantia nigra (happen from loss of dopaminergic neurons).
- Damage happens in nigrostriatal pathway , ascends from substantia nigra to corpus striatum –> reduced inhibitory effect of dopamine pathways on extrapyramidal motor symptoms —> exaggerated excitatory effects on Ach pathway -> = loss of GABAergic, non-adrenergic and serotonergic neurons.
Types of PD:
- several Neurological, vascular and drug induced conditions = Parkinson plus syndrome PPS.
- Idiopathic PD - unknown cause. most common described below.
- Vascular PD from restricted blood supply to brain (stroke, brain injury)
-Drug induced PD - Some drugs can cause it = AED, antipsychotics, metoclopramide, cinnarizine, amiodarone, lithium, methyldopa
Signs and symptoms/ Diagnosis
4 Main- signs need 2 of the first 3 to diagnose, the 4th appears 8 years after.
Signs: Resting tremor, Rigidity, Bradykinesia, Postural instability
TREMOR:
- Shakiness/Nervousness, - starts in one upper extremities, and initially may be intermittent. Usually begin in the fingers or thumbs but can start in the forearm or wrist. After several months may spread to lower extremity.
- Tremor may vary by patient, can come from stress, anxiety, or fatigue but can disappears with intention to action or use limb and resolves during sleep but not seen in all patients. Can affect head or neck, chin or lip.
Tested:
- 1st - relax arms on legs while in seated position and count backwards from 10
- 2nd - arm is observed in a outstretched position to asses postural tremor
- 3rd - finger to nose test (patent move index finger between drs extended finger and tip of their nose)
BRADYKINESIA:
- Slowness on movement, found on physical examination, loss of dexterity fatigability or aching when performing repeated actions.
- Facial bradykinesia decreased blink rate, blank facial expression. speech can be softer, less distinct or more monotonal. more advanced cases speech is slurred, poorly spoken, difficult to understand. Drooling too.
- Truncal bradykinesia = slowness or difficulty rising from chair, turning in bed or walking.
- freezing is more prominent in doorways or narrow areas can result in patients getting trapped behind stuff.
- lower extremities unilateral bradykinesia can cause feet scuffing the ground.
Tests:
- Handwriting samples - recorded to keep progress notes to monitor disease progression.
- Patients blinking rate and facial expression, speed and amplitude of movements. (Open hand for each limb individually and tap the fingers repetitively as hard and fast as possible then by tapping each foot same way. arise from seated position with arms crossed to asses ability to arise from a chair and stride length and speed as well as arm swing).
Hypokinesia - (slow movements)
RIGIDTY:
Forms= Cogwheel, lead pipe.
- Health professional holds the patients arms and tries to bend it either feels stiff, like bending a lead pipe, or moves in small rapid jerks because the muscle groups dont work together proper.
Tests: By flexing and extending the patient relaxed wrist, resistance to passive movement in a joint.
DYSTONIA:
- range of movements disorders that cause muscle spasms and contractions
- Common in young adults
- Cramping or aching and tendency of the extremity to turn in or the greater toe to dorsiflex, curling, inversion, or plantar flexion.
POSTURAL INSTABILITY:
- Refers to imbalance and loss of righting reflexes.
- milestone BC poor amenable to treat and can start disability in late disease.
Test: Patient stand with eyes open and pulls their shoulders back towards examiner then told to be ready for displacement and regain balance ASAP
- None or <2 steps backwards is normal.
LARYNGEAL DYSFUNCTION AND DYSPHAGIA:
- Sustaining vowel phonation for max time, counting to 50 and reading passage testing articulation used as speech samples.
Tests: Listen closely for = reduced or diminishing loudness and intonation and increasing breathiness and hoarseness, soft monotone voice, vocal tremor, poor articulation, variable speech rate, trouble starting speech, and stuttering-like qualities or the marked contrast between reduced vocal volume and the loud vocal volume.
Signs and symptoms/ Diagnosis 2
AUTONOMIC DYSFUCNTION AND CARDIOPULMONARY IMPAIRMENT:
- Orthostatic Hypotension in late disease
- Impaired intestinal motility leads to constipation, vomiting and impaired absorption.
- Urinary incontinence, retention, balder infection can occur.
- ED uncommon and EPs of sweating
- Flexed posture can lead to kyphosis, reduction in pulmonary capacity, restrictive lung disease pattern
DEPRESSION AND DEMENTIA:
- Should be regularly screened for depression from early diagnosis. assessment complicated BC symptoms of PD and depression overlap (mask like face, insomnia, difficulty concentrating, fatigue)
- Substantia cognitive impairment and dementia occur 8 years after motor symptoms.
RAPID EYE MOVEMENT (REM) SLEEP BEHAVIOUR DISORDER:
- RBD if med review addressed pharmacological causes.
Motor v non motor symptoms?
Motor
Hypokinesia, Bradykinesia, Tremor, Rigidity, postural instability
Non-Motor
Dementia, Depression, Sleep issues, Bladder/Bowel dysfunction, Speech/Language changes, Swallowing issues (dysphagia), Weight loss
Treatment
Aim:- provide control over signs and symptoms, reduce adverse effects.
NON DRUG TREATMENT:
- Physiotherapy, speech and language therapy, swallowing or saliva problems, occupational therapy.
- Diet = eat protein in final meal
DRUG TREATMENT:
1st LINE:
Motor symptoms decrease quality of life =
- Levodopa +carbidopa/Benserazide
(co-careldopa or co-beneldopa)
Motor symptoms dont affect quality of life =
- Levodopa OR non-ergot-derived dopamine-receptor agonists (pramipexole, ropinirole, rotigotine) OR monoamine-oxidase-B inhibitors (rasagiline, selegiline HCl).
ADJUVANT:
- If develops dyskinesia or motor fluctuations = specialist advise B4 treatment change.
- dyskinesia or motor fluctuations despite optimal Ldopa + choice of non-ergotic dopamine-receptor agonists (pramipexole, ropinirole, rotigotine), MAO-B inhibitors (rasagiline, selegiline) or COMTi (entacapone, tolcapone).
- Ergot-derived dopamine-receptor agonist (bromocriptine, cabergoline, pergolide) ONLY IF NON ERGOT FAILS.
- ALL Above FAIL for dyskinesia control = use Amantadine HCl.
ADVANCED PD:
- Offer Apomorphine intermittent injections or continuous SC infusions.
- N+V with apomorphine use = domperidone 2 days b4 apomorphine start then stopped ASAP. To reduce QT prolongation risk which = arrhythmia. Should asses ECG and cardiac risk factors b4 starting.
- Levodopa-carbidopa intestinal gel = Advanced PD with severe motor fluctuations hyperkinesia or dyskinesia. done via portable pump in duodenum or upper jejunum.
- Deep brain stimulation = Advanced PD whose symptoms not controlled by other therapies.
Symptomatic treatments (know pathways)
- N+V = If Ldopa related then reassure it settles after a while. If severe N+V/ unrelated Ldopa or dopamine agonists AVOID metoclopramide/prochlorperazine they can worsen Parkinson’s. TRY low dose domperidone (reduce/stop when it settles)
- Constipation = use laxative ALT enema.
- Drooling = Glycopyrronium bromide ALT BOTOX.
- PD dementia = AchE inhibitor (donepezil, rivastigmine galantamine). ALT memantine.
- Psychotic (hallucinations/delusion) = Review and educate family members/helpers. Reduce causative PD drug dosages. Quetiapine ALT clozapine - (Must be no cognitive impairment). Other antipsychotics worsen EPS in Parkinson
- Orthostatic (Postural) hypotension = Adjust meds (antihypertensive, dopaminergic, anticholinergics, antidepressants). Midodrine ALT fludrocortisone
- Nocturnal akinesia (difficulty to move whilst sleeping/get up to pee) = L-dopa, oral dopamine agonists. ALT rotigotine
- Excessive Daytime sleepiness/Sudden onset sleep = Modafinil – not for pregnant or planning to be. Review every yr.
- Depression/Anxiety - Refer to specialist - SSRIs (worsen motor symptoms) TCA (AE cognitive impairment or falls risk higher)
REM - clonazepam or melatonin to treat
Impulse control disorders:
- EG gambling, hypersexuality, binge eating obsessive shopping.
- This can develop if on dopaminergic drugs.
- REDUCD DOSE OF drugs
- CBT if above FAIL
Palliative care
- Discuss with family concerns etc.
- What’s going to happen next etc
PRSC extra notes
AVOID abrupt withdrawal of anti-Parkinson drugs - Prevents AEs
- learn the common dispended drugs not RARE 1s
Sudden onset of sleep and Impulse control disorders with Dopamine agonists (Pramipexole, Ropinirole, Rotigotine)
- Above symptoms less likely with Ldopa but Ldopa can cause more motor issues (dyskinesia’s)
SAFTEY INFO:
Impulse control disorders can develop with dopaminergic drugs esp. if PT has exp. with impulse disorder.
Fibrotic reactions - Monitor for Dyspnoea, Persistent cough, chest pain, cardiac failure & Abdo pain.
COMTi: [EXAM Q]
- Tolcapone - Liver toxicity recognise signs (NV, Anorexia, Fatigue, Abdo pain, Dark urine)
- Entacapone: Discolour urine (red/brown)
ALL drugs
Hypotensive reactions/Sudden onset sleep when 1st starting
Colour urine: Majority of Anti parkinson drugs colour urine - LABEL 14
DRUG treatment cessation
NEVER STOP drugs abruptly or decrease dose suddenly - Increase risk of neuroleptic malignant syndrome.
NV- Domperidone MAIN drug (EXAM Q)
- AVOID metoclopramide - increases chance of EPS symptoms, Exacerbates Parkinson’s and antagonises some drugs (EXAM Q)
Apomorphine - use domperidone 2 days b4 for NV then STOP ASAP
